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C 2005)
AIDS and Behavior, Vol. 9, No. 4, December 2005 (
DOI: 10.1007/s10461-005-9014-1
Condom Attitudes and Behaviors Among Injection
Drug Users Participating in California Syringe
Exchange Programs
Laura M. Bogart,1,5 Alex H. Kral,2 Andrea Scott,2 Rachel Anderson,3
Neil Flynn,3 Mary Lou Gilbert,1 and Ricky N. Bluthenthal1,4
Published online: Oct. 26, 2005
This study examined condom attitudes, preferences, barriers, and use among a sample of 550
injection drug using clients of syringe exchange programs in California. In multivariate analyses, positive attitudes toward condoms were significantly associated with consistent condom
use for vaginal, anal, and oral sex in the past six months, beyond the effects of confounding
socio-demographic and HIV risk variables. Participants commonly cited partner-related barriers to condom use, such as reluctance to use condoms with steady partners (34%). Almost a
quarter of the sample cited dislike of condoms (e.g., because of pleasure reduction). In addition, a third of respondents stated specific preferences regarding condom brands, sensitivity,
sizes, and textures. Interventions that increase awareness about positive aspects of condom
use and sexual risk from steady partners may be successful in increasing condom use among
injection drug users.
KEY WORDS: injection drug use; syringe exchange; condom use; condom attitudes.
INTRODUCTION
male IDUs, in particular, are likely to engage in commercial sex work, which places them at increased sexual risk (Anderson et al., 1996; Booth et al., 1993,
2000; Corby et al., 1996; Siegal et al., 1996; White
and Phillips, 1993). Given these high levels of sexual
risk behaviors, there is a clear public health need to
identify factors that influence patterns of condom use
among male and female IDUs.
The results of prior research, conducted mainly
with non-IDU samples, suggest that individuals’
failure to use condoms can be understood within the
context of condom-related attitudes. Condom use
intentions and behaviors tend to be higher among
individuals who like condoms and who perceive few
barriers to condom use. In particular, two recent
meta-analyses indicated that positive attitudes about
condom use are strongly related to condom use intentions (r = .45) and moderately related to condom
use behaviors (r = .32) (Sheeran et al., 1999; Sheeran
and Taylor, 1999). Studies investigating these
relationships among IDUs have found positive
attitudes toward condom use, and significant
HIV prevention among injection drug users
(IDUs) has tended to focus on the reduction of needle sharing. Fewer prevention efforts have targeted
sexual risk among IDUs, although sexual risk is a major route of transmission of HIV even among IDUs
(Kral et al., 2001; Strathdee et al., 2001). Prior research has found low levels of condom use among
IDUs, especially with steady partners and among
those who are also using crack cocaine. Further, fe1 Health
Program, RAND Corporation, Santa Monica, California.
of Family and Community Medicine, Urban Health
Studies, UC, San Francisco.
3 Department of Internal Medicine, Division of Infectious Diseases, UC, Davis.
4 Drew Center on AIDS Research, Education, and Services, Department of Psychiatry, Charles R. Drew University of Medicine
and Science, Los Angeles, CA.
5 Correspondence should be directed to Laura M. Bogart, Health
Program, RAND Corporation, 1776 Main Street, Santa Monica,
California 90407-2318; e-mail: [email protected]
2 Department
423
C 2005 Springer Science+Business Media, Inc.
1090-7165/05/1200-0423/0 424
Bogart, Kral, Scott, Anderson, Flynn, Gilbert, and Bluthenthal
associations between attitudes about condoms
and condom use intentions and behaviors, especially for casual partners (Belanger et al.,
2002; Corby et al., 1996; Falck et al., 1997;
Fernandez et al., 1997; Kasprzyk et al., 1998;
Peterson et al., 1992; Schilling et al., 1991). Moreover,
qualitative and quantitative research has identified
several barriers to condom use among IDUs, including general dislike of condoms, low perceived risk
of HIV, and the beliefs that condoms are difficult
or inconvenient to use, and are not necessary with
monogamous or steady partners (Corby et al., 1996;
Weiss et al., 1993; White and Phillips, 1993).
Although prior research has provided some insight regarding condom attitudes among IDUs, the
majority of this work has not examined attitudes
among samples consisting entirely of IDUs and has
instead combined heterogeneous samples of IDUs
and other individuals who engage in high-risk behaviors (e.g., men who have sex with men, or individuals who use non-injecting drugs) (Kramer et al., 1991;
Peterson et al., 1992). Because unprotected sexual
intercourse is a growing risk factor for HIV among
IDUs and their sexual partners, it is important to
study IDUs’ attitudes and behaviors separately from
those of other individuals, who may only be at risk
through their sexual behavior.
Further understanding of the different facets of
attitudes toward condom use among IDUs would
aid in the development of interventions designed
to increase positive attitudes about condoms and
decrease sexual risk. In the present study, we conducted a comprehensive investigation of condom
use attitudes and barriers among IDUs participating in California syringe exchange programs
(SEPs). Because prior research has shown that
IDUs are less likely to use condoms with their
primary, versus their casual or sex work-related,
partners (Falck et al., 1997; Rhodes and Malotte,
1996; Vanichseni et al., 1993; for a review see Misovich et al., 1997), we examined condom attitudes
separately for IDUs with only one recent sexual
partner and IDUs with multiple recent sexual partners. In addition, to our knowledge no research
has investigated the specific characteristics of condoms preferred by IDUs. Thus, we also examined
the preferences that IDUs have for different types
of condoms (e.g., in terms of different brands, sensitivity, sizes, and textures). Information about IDUs’
condom preferences may be useful in planning programs for distributing condoms and disseminating
prevention information.
METHODS
The present dataset is part of a larger study addressing the impact of California law Assembly Bill
136 (AB136) on SEPs and their clients. AB136 was
enacted in January 2000 and grants local jurisdictions (cities and counties) in California the authority to legalize SEPs pursuant to a declaration of a local public health emergency. Although local jurisdictions may declare health emergencies, no state funding has been allocated to support operating SEPs.
Procedures
Convenience samples of an average of 23 clients
(range = 7–25) from each of 23 participating SEPs
(550 clients total) were interviewed in 2002. Although refusal rates were not systematically collected, anecdotal reports from research staff indicated that most refusals were due to a lack of time
to complete the assessment, or fear that remaining
in the SEP area to complete research procedures
would increase the chances of arrest. The 23 SEPs
represented 96% of the programs operating in California in 2000, when program recruitment occurred.
SEPs from rural (n = 200, 37%; e.g., Native American reservation) and urban (n = 347, 63%; e.g., Los
Angeles) areas in the state were involved, operating in 15 California Counties and all major cities in
the state. Eligibility criteria included injection drug
and syringe exchange utilization in past 30 days. After determination of eligibility and provision of informed consent, participants were interviewed with a
structured survey by a trained interviewer/counselor
in a private space. Private spaces varied by field
location and included rooms in SEP offices, cars,
park benches, temporary tents, sidewalks, and participants’ homes. Participants’ responses were entered
into a software program by study interviewers on
lap-top computers (computer assisted personal interview, NOVA Research, Bethesda, MD, USA). Participants also received HIV testing and pre- and post
testing counseling.
Participants were paid $10 United States for the
interview and asked to return for HIV test results disclosure and counseling one to two weeks later.
Study Assessment
The assessment included items on HIV risk behaviors (i.e. drug injection and sexual practices),
Condom Attitudes Among IDUs
HIV/AIDS/Hepatitis C virus knowledge, medical
history, incarceration history, SEP utilization, and
utilization of other social and medical services. The
variables of interest in the present analysis are described in detail below.
Socio-Demographics
Standard questions were used to assess participants’ age, gender, race/ethnicity, education
level, income from all sources in the last 30 days, and
sexual orientation (self-identified), and whether participants had received income from part-time, fulltime, or odd jobs in the past 30 days. The reference
group for race/ethnicity was White.
HIV Status and Sexual Risk Factors
Participants were tested for HIV with Orasure
oral tests, and specimens were analyzed for HIV
antibodies using enzyme immunoassay (EIA). EIApositive specimens were confirmed using Western
blot assay (Wb). Criteria for a seropositive Wb result were the presence of reactive bands at two of the
following locations: p24, gp41, and gp120/160 as described by the Centers for Disease Control and Prevention (1989).
Partner-related HIV risk was assessed with several questions about partners in the past six months.
Specifically, participants were asked the number of
male and female partners that they had, whether
they had a steady partner, and whether they had
paid or been paid money or drugs for sex in the last
six months. The number of male and female partners
reported was combined and recoded as “one” or
“more than one” partner in the last six months in the
analyses.
Condom Preferences and Barriers
Participants were asked two open-ended questions regarding their condom preferences and
reasons for not using condoms: “What brand of
condom, if any, do you prefer?” and “When you
have sex, what are the reasons why you do not always
use condoms?” Two raters coded all of participants’
responses to these questions. Consistency between
raters was calculated for 100 of the responses to each
question. Consistency was perfect for condom char-
425
acteristics and brands (κ = 1.00, p < .01) and excellent for barriers to condom use (κ = .88, p < .01).
Participants were also asked whether they had
ever used a condom, whether they had ever used
lubricant with condoms, and the extent to which
they find condom use difficult or easy (with response
options “very easy,” “easy,” “neutral,” “hard,” and
“very hard”). In addition, they were asked four
closed-ended questions assessing their preferences
for different types of condoms, in terms of texture
(“ribbed/dotted,” “no texture,” or “plain,” “no
preference”); size (“extra large/larger/extra headroom,” “tight fitting/snugger,” “no preference”);
lubrication (“lubricated” or “not lubricated”), and
thickness (“thin/extra-sensitive/heat sensitive,”
“thick/desensitive/extended pleasure,” “regular,”
“no preference”).
Condom Attitudes
Condom attitudes were measured with an eightitem scale adapted from the Attitudes Toward Condom Scale (Brown, 1984). Sample items include, “In
my opinion, condoms are too much trouble,” and “I
don’t think condoms interfere with the enjoyment
of sex.” Each item was rated on a five-point Likert
scale with response options “strongly disagree,” “disagree,” “undecided,” “agree,” and “strongly agree.”
After reverse-scoring negative attitudinal items, all
items were summed for an overall measure, in which
higher scores represented more positive attitudes toward condoms (possible range = 8–40). The scale
was found to have satisfactory internal consistency
(α = .73).
Condom Use Behavior
Participants were asked the percentage of time
that they used latex condoms for vaginal, anal, and
oral sex in the past 6 months. Responses were dichotomized into 0% (never) 1% to 99% (sometimes)
or 100% condom use (“always”).
Statistical Analysis
Descriptive statistical information (e.g., means,
frequencies, variability) was examined for all
study variables. Bivariate associations were examined among socio-demographic factors, HIV
risk variables, condom attitudes, and condom use
426
Bogart, Kral, Scott, Anderson, Flynn, Gilbert, and Bluthenthal
behavior. Pearson correlations were used to assess
relationships between two continuous variables
(e.g., condom attitudes and age), point-biserial
correlations were used to examine relationships
between continuous and categorical variables (e.g.,
condom attitudes and condom use), and Spearmanrho correlations were used to examine associations
between two dichotomous variables (e.g., gender
and condom use). Multivariate linear regression was
used to predict condom attitudes, controlling for all
variables that were significantly related to condom
attitudes in bivariate analyses (p < .05). Multivariate
logistic regression was used to predict condom use
behavior (never or sometimes versus always) with
condom attitudes for vaginal, anal, and oral sex
separately, controlling for all variables that were
significant across bivariate analyses for the three
types of condom use behaviors.
Prior research suggests that IDUs with steady
partners are less likely to use condoms (e.g., Misovich et al., 1997), although no research to date
has provided an in-depth analysis of condom attitudes among IDUs with different partnership patterns. Thus, in addition to conducting analyses for the
overall sample, we also examined all relationships
separately for those who reported one partner, versus multiple partners, in the past six months. Analyses regarding condom use were limited to those individuals who reported having at least one partner in
the past six months; all other analyses included both
sexually-active and non-sexually-active respondents.
An alpha level of 0.05 was used as the cut-off for statistical significance.
RESULTS
Socio-Demographic Characteristics and HIV Status
Most of the sample (70%) was male; half were
White, 23% Black/African American, 20% Latino,
4% Native American, less than 1% Asian/Pacific
Islander, and 2% “other.” Of those identifying as
Latino, the majority were Mexican or Mexican
American (88%). The majority (63%) had completed high school or greater. Almost a fifth had no
job in the past month, about half had odd jobs only,
16% had part-time jobs, and 19% had full-time jobs.
Income in the last month ranged from 0 to $15,000
(Median = 774.50; Interquartile Range = 397.50–
1200.00). The majority was heterosexual (85%), and
15% self-identified as gay/bisexual/lesbian. Almost
5% tested positive for HIV antibodies, which is comparable to other SEP and non-SEP IDU samples in
California (Bluthenthal et al., 2001; Hahn et al., 1997;
Longshore and Anglin, 1992; 1994; Longshore et al.,
1998).
Condom Preferences
The majority of participants (80%) had previously used condoms. Of these, most (67%) had no
preference regarding condom texture, 16% preferred
no texture, and 15% preferred ribbed or dotted condoms. In addition, 46% had no preference regarding
condom size; smaller proportions preferred regular
size (21%), tight or snug fitting (16%), or extra large
(14%) condoms. The majority (62%) preferred lubricated condoms, almost 30% had no preference, and
a minority (7%) preferred non-lubricated condoms.
Although many (43%) had no preference regarding
the sensitivity of their condoms, 29% preferred thin,
extra sensitive, or heat sensitive condoms, 11% preferred thick, desensitizing, or extended pleasure condoms, and 13% preferred regular condoms.
The open-ended qualitative data regarding respondents’ preference for different types of condom
brands (n = 413) indicated that two-thirds of respondents had no preference regarding the type of condom they used, with some stating that they would
use anything that was free and/or available. Trojan
was the most commonly endorsed brand, preferred
by 17% of respondents; fewer numbers of respondents (13%) preferred other brands (e.g., Durex,
Lifestyle). Although respondents were asked about
brand preferences, a handful of respondents (6%)
did not list specific brands, but stated that they preferred condoms with certain characteristics, such as
latex, flavored, or colored.
Barriers to Condom Use
Participants reported several reasons for not using condoms (See Table I). Partner-related reasons
were the most prevalent, with over a third stating
that they did not use condoms because they were in
a long-term, steady or marital relationship. Some of
the partner-related reasons seemed to stem from a
belief that partners were low in risk for HIV (e.g.,
partner was tested for HIV or other sexually transmitted infections, partner is “safe”). Several participants had misconceptions about HIV risk, with 4
Condom Attitudes Among IDUs
Table I.
427
Participant-Generated Barriers to Condom Use
Among IDUs in California (n = 440)
Reason
Partner-related (total %)
Monogamy/long-term, steady partner
In love/trust/know partner/feel safe
Partner clean/not at risk (no diseases)
Partner does not want to use condoms
Oral sex only (not risky/do not like taste)
Cannot get pregnant/Trying to have children
Both partners HIV-positive
Female partner only - low risk
Dislike of Condoms (total %)
Do not like condoms/the way condoms feel
Break/do not work correctly/difficult to use
Uncomfortable/do not fit/lose erection
Break spontaneity/interfere with mood
Availability (not available, inconvenient to use)
Ignorant/apathetic about risk/careless
Alcohol/drug use interfered
No reason/don’t know
Other
%
57
34
8
4
3
3
3
1
1
33
24
4
3
2
12
9
2
3
8
Note. Percentages add up to greater than 100% because some
respondents stated more than barrier.
Table II. Frequency Distributions of Condom Use for Vaginal,
Anal, and Oral Sex among Sexually-Active IDUs in California
Condom Use
(%)
Oral
Women with men
0
72 (70%)
1–99
16 (16%)
100
15 (15%)
Men with women
0
163 (91%)
1–99
6 (3%)
100
11 (6%)
Men with men
0
15 (65%)
1–99
4 (17%)
100
4 (17%)
One partner
0
146 (93%)
1–99
6 (4%)
100
5 (3%)
Multiple partners
0
121 (72%)
1–99
22 (13%)
100
56 (35%)
Anal
Vaginal
12 (52%)
3 (13%)
8 (35%)
78 (59%)
24 (18%)
31 (23%)
34 (68%)
4 (8%)
12 (24%)
146 (57%)
53 (21%)
59 (23%)
9 (23%)
15 (38%)
15 (38%)
—
—
—
29 (83%)
3 (9%)
3 (9%)
171 (76%)
19 (8%)
34 (15%)
26 (34%)
19 (25%)
32 (42%)
53 (32%)
58 (35%)
56 (35%)
Note. Percentages may add up to greater than 100% due to
rounding.
respondents believing condoms are not necessary if
both partners are HIV-positive, and 4 respondents
stating that condom use was not necessary with female partners.
The second most prevalent set of reasons
were related to dislike of condoms, both in general, and because of specific aspects of condoms,
such as discomfort (3%), difficulty of use (4%),
and interference with spontaneity (2%). A quarter
of participants did not use condoms because they did
not like them, thought that intercourse was better
without them, or felt that they reduced sensitivity and
pleasure.
Other perceived barriers were related to condom availability, risk perception, and substance use.
Over 10% of participants did not use condoms because they did not have one available or they found
condom use inconvenient. Other participants (9%)
did not think that they were at risk, were apathetic
about the risks, or simply did not think about using
condoms. Only 8 participants reported not using condoms because they were under the influence of alcohol or drugs.
Additional analyses indicated that barriers to
condom use differed by gender and partner status.
Women (53%) were more likely than men (26%) to
state that they did not use condoms because they had
a long-term, steady partner,χ2 (1) = 28.85, p < .001,
and men (26%) were more likely than women (11%)
to report that they disliked condoms, χ2 (1) = 16.93,
p < 001. Not surprisingly, compared to those with
multiple partners in the past six months (20%), individuals with only one partner (47%) were more
likely to report that their lack of condom use was
due to their monogamous status, 20% vs. 47%;
χ2 (1) = 25.46, p < .001.
Condom Use Behaviors
The complete frequency distributions of condom use in the past six months are provided in
Table II. The majority of respondents reporting sexual intercourse in the past six months did not use
condoms consistently. Of those reporting vaginal intercourse (n = 391), only 23% always used condoms.
Of those reporting anal intercourse (n = 93), only
28% reported always using condoms; and of those
reporting oral sex (n = 310), only 8% always used
condoms.
Predictors of Condom Attitudes and Condom Use
In general, respondents reported positive attitudes toward condoms; the average sum of the condom attitude items was 28.80 (SD = 5.18) on a scale
428
Bogart, Kral, Scott, Anderson, Flynn, Gilbert, and Bluthenthal
Table III. Bivariate Relationships of Condom Attitudes and Sex Risk Behaviors among IDUs in California
Condom
Attitudes
Age
Female
Years of education
Black
Latino
Other race
Income (last 30 days)
Gay/bisexual
Not currently employed
HIV-positive
Multiple partners, last 6 mos
Steady partner, last 6 mos
Paid sex partner, last 6 mos
Paying sex partner, last 6 mos
Consistent Condom Consistent Condom Consistent Condom
Use (Vaginal)
Use (Anal)
Use (Oral)
−.09
.15∗∗
.10∗
−.02
−.17∗∗
.01
−.00
.21∗∗
−.04
−.04
.16∗∗
−.14∗
.11∗
.20∗∗∗
−.05
.01
.05
−.03
−.02
−.01
−.02
.30∗∗∗
.04
.01
.22∗∗∗
−.24∗∗∗
.16∗∗
.25∗∗∗
−.11
.09
−.10
−.11
−.03
.19
−.10
.19
.03
−.02
.31∗∗
−.23∗
.07
.43∗∗∗
.08
.04
.05
−.01
.01
.04
−.11
.11∗
.06
.05
.19∗∗
−.18∗∗
.02
.12∗
∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001.
with a possible range of 8–40. Table III shows correlations of condom attitudes with socio-demographic
factors, HIV status, and partner-related risk behaviors. Respondents who were female, better educated,
White, and gay/bisexual/lesbian were more likely to
report positive attitudes towards condoms. In addition, participants with more positive attitudes about
condoms were more likely to have had more than
one sex partner or to have traded sex for money
or drugs, and less likely to have had a steady sex
partner, in the past six months. In multivariate analyses that included variables with significant bivariate effects, White race/ethnicity, β = −.11, p < .05,
gay/bisexual/lesbian orientation, β = .21, p < .001,
and not having a steady partner, β = −.17, p < .01,
continued to be significant predictors of more positive condom attitudes.
Additional analyses indicated different patterns
of condom attitude relationships by partnership patterns (not shown in table). Among IDUs with only
one partner in the past six months, bivariate analyses indicated that gay/bisexual/lesbian orientation
and HIV status were related to more positive attitudes toward condoms in both bivariate, r = 21,
p < .01 and r = .15, p < .05, respectively, and multivariate, β = .22, p < .01 and β = .15, p < .05, respectively, analyses. Among those with multiple sexual
partners, in bivariate analyses gay/bisexual/lesbian
orientation, r = .23, p < .01, and being paid for sex,
r = .27, p < .001, were associated with more positive condom attitudes, and Latino ethnicity, r = −.29,
p < .001, was associated with less positive attitudes.
Latino ethnicity, β = −.28, p < .001, sexual orientation, β = .18, p < .05, and sex work, β = .20, p < .01,
continued to show significant associations in multivariate analyses.
In bivariate analysis predicting condom use
(Table III), we found that having multiple partners,
and engaging in exchanges of sex for money or drugs,
were significantly related to consistent condom use
for all sex acts. Having a steady partner in the past six
months and self-identifying as heterosexuals was associated with using condoms inconsistently or never
in the past six months. Thus, patterns of associations with condom use were similar across sexual
behaviors overall, with the exception of sexual orientation, and sex work. Gay/bisexual/lesbian orientation was associated with consistent condom use
for vaginal and oral sex, but not for anal sex. Having paid sex partners was related to consistent condom use for vaginal sex, but not for anal or oral
sex.
We further explored these relationships by partnership patterns (not shown in table). In bivariate
analyses, among IDUs with one sexual partner in the
past six months, consistent condom use for vaginal
sex was related to gay/bisexual orientation, r = .16,
p < .05, and paying for sex in the past six months,
r = .20, p < .01; consistent condom use for oral sex
was related to having been paid for sex, r = .20,
p < .05. Among IDUs with multiple partners, consistent condom use for vaginal sex was associated with
gay/bisexual orientation, r = .29, p < .001, and having been paid for sex in the past six months, r = .27,
p < .01; being paid for sex was similarly related to
condom use for anal sex, r = .41, p < .01. None of the
measured variables were significantly associated with
using condoms for anal sex among those with one
Condom Attitudes Among IDUs
429
Table IV.
Unadjusted (Bivariate) and Adjusted (Multivariate) Associations Between Condom Attitudes and Condom Use
Among Sexually-Active IDUs in California
Consistent condom use
Overalla
Vaginal sex (n = 314)
Anal sex (n = 75)
Oral sex (n = 256)
One recent partnerb
Vaginal sex (n = 169)
Anal sex (n = 23)
Oral sex (n = 121)
Multiple recent partnersc
Vaginal sex (n = 149)
Anal sex (n = 54)
Oral sex (n = 139)
Unadjusted
(point biserial)
Correlations
with condom
attitudes
Adjusted odds
ratios and 95%
confidence
intervals with
condom
attitudes
.36∗∗∗
.37∗∗
.21∗∗
1.2 (1.1–1.3)∗∗∗
1.3 (1.1–1.5)∗∗
1.2 (1.0–1.3)∗∗
.23∗∗
.30
.10
1.1 (1.0–1.2)∗∗
1.4 (0.9–2.3)
1.1 (0.9–1.4)
.44∗∗∗
.33∗
.25∗∗
1.2 (1.1–1.4)∗∗∗
1.1 (1.0–1.3)
1.2 (1.1–1.4)∗∗
Note. Sample sizes apply to adjusted models and are nearly identical for unadjusted models. Condom attitudes is the independent
variable, and condom use (for vaginal, anal, or oral sex) is the outcome.
a Overall regression models adjusted for gender, sexual orientation, steady partner status, education, and being paid for sex.
b Regression models for participants with one recent partner adjusted for sexual orientation and having paid for sex.
c Regression models for participants with multiple recent partners
adjusted for sexual orientation and being paid for sex.
∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001.
partner, or using condoms for oral sex, among those
with multiple partners.
Relationship of Condom Attitudes to Condom Use
Positive attitudes toward condoms were significantly associated with consistent condom use for
vaginal, anal, and oral sex in the past six months (see
Table IV). In a multivariate logistic regression analysis, more positive attitudes toward condoms significantly predicted condom use behavior for vaginal,
anal, and oral sex in the past six months among all
participants, controlling for confounding variables.
Effect sizes were relatively similar by partnership patterns. However, some effects were not significant, most likely due to small samples sizes for some
of the relationships. Condom attitudes were independently related to condom use for vaginal sex among
IDUs who were monogamous in the past six months,
whereas condom attitudes were independently related to condom use for both vaginal and oral sex
for IDUs reporting multiple partners in the past six
months.
DISCUSSION
In the present study, we found robust relationships between attitudes toward condom use and condom use behaviors for the overall sample, among
those who were monogamous, and among those who
had multiple sexual partners, beyond the effects of
socio-demographic and risk characteristics. Moreover, the majority of relationships examined were
consistent across sexual behaviors, with similar associations observed with condom use for vaginal, anal,
and oral sex. These results, which are consistent with
findings from IDU and non-IDU samples (Sheeran
and Taylor, 1999), suggest that interventions that aim
to change condom attitudes may have corresponding
influences on condom use behaviors. Accordingly,
positive changes in beliefs about condoms partially
accounted for the reduction in participants’ risk behaviors in the NIMH Multisite HIV Prevention Trial,
a large-scale intervention for men and women at high
risk for HIV (The NIMH Multisite HIV Prevention
Trial Group, 2001). It is important for prevention
programs targeting IDUs to develop such interventions specific to the needs and lives of IDUs.
Partner-related concerns, such as reluctance to
introduce condoms with steady partners, ranked first
among the participant-generated barriers to condom use. In line with prior qualitative and quantitative research (Ames et al., 1995; Carballo-Dieguez
and Dolezal, 1996; Choi et al., 1994; Kenen and
Armstrong, 1992; Misovich et al., 1997; Weiss et al.,
1993), respondents were unwilling to use condoms
with their steady partners, because they believed
condom use connotes distrust and a lack of intimacy, because they did not feel that their partner was
at risk, or because they felt that condom use with
long-term partners was unnecessary. Interestingly,
the quantitative analyses indicated that these beliefs
may depend on sexual orientation and HIV status.
Among IDUs who had one sexual partner in the past
six months, those who were gay/bisexual/lesbian and
those who were HIV-positive had more favorable attitudes toward condoms. In contrast, those with multiple partners had more positive attitudes, and were
more likely to protect themselves in sexual encounters, especially if they engaged in sex work. These results are consistent with prior studies showing that
female injection drug and/or crack users were more
likely to use condoms if they were HIV-infected, but
only with their main partners (Wood et al., 1998),
as well as research demonstrating a higher likelihood of condom use with riskier sexual partners (i.e.,
430
Bogart, Kral, Scott, Anderson, Flynn, Gilbert, and Bluthenthal
casual and sex work partners) among IDUs (Falck
et al., 1997; Rhodes and Malotte, 1996; Vanichseni
et al., 1993). Nevertheless, even if IDUs are not at
risk for HIV from sexual behavior, they may still
be at risk via injection-related behaviors. The design
of couples-based interventions would be helpful in
counseling IDUs about these issues, as an important
and large sub-population of IDUs have steady sexual
partners. Such interventions could, for instance, address misconceptions about sexual risk from steady
partners, as well as integrate family planning components that inform participants about a range of birth
control methods.
Consistent with prior research on both IDUs
and non-IDUs (e.g., Corby et al., 1996; HelwegLarsen and Collins, 1994; Somlai et al., 2003), respondents had only moderately positive attitudes toward condoms, possibly because condom attitudes
are composed of beliefs with opposing valences [e.g.,
that condoms both are effective and reduce pleasure
(Brown, 1984; Norton et al., in press)]. Moreover, dislike of condoms was a major barrier to condom use,
ranking second after partner-related concerns and
expressed by nearly a quarter of the sample. These
results are consistent with prior qualitative and quantitative research examining barriers to condom use
among IDU and non-IDU samples. For example, dislike of condoms due to reduction in sexual pleasure
is a commonly-cited reason for not using condoms
(Carballo-Dieguez and Dolezal, 1996; CarballoDieguez et al., 1997; Geringer et al., 1993; Stall et al.,
1990); and dislike of condoms has been strongly related to condom use behavior (Helweg-Larsen and
Collins, 1994; Monahan et al., 1997; Norris and Ford,
1994; Wulfert et al., 1996). Somewhat surprisingly, interference with spontaneity, which has been identified as a key barrier in prior quantitative research
(Monahan et al., 1997; Norris and Ford, 1992), was
not cited as a reason for lack of condom use in
our study. However, these results are consistent with
those of a recent review of research on men’s condom
attitudes, which observed that dislike of condoms is
a more prevalent barrier to condom use than is lack
of spontaneity (Norton et al., in press). We suspect
that the discordance between our results and those of
others is partially due to the qualitative methodology
used, and that lack of spontaneity may have emerged
as a stronger barrier had participants been directly
asked to rate specific barriers such as spontaneity
on a scale. In general, however, our results point to
the need to consider negative affective responses to
condoms when designing interventions to increase
condom use. Such interventions could focus on extolling the pleasurable aspects of condoms, as well
as showing participants ways to eroticize condom
use.
The majority of the sample stated that they
had no preferences in terms of the types of condoms that they used. However, a third of participants
expressed specific preferences regarding particular
brands, sizes, lubrication, and textures. Although the
observed preferences may be specific to our sample,
they do suggest that SEPs and condom distribution
programs could conduct brief surveys of client preferences in order to determine which condoms to offer. Clients may be more receptive to condom use
when condoms that they prefer are made available.
In addition, condom distribution programs that are
tailored to the preferences of their clientele are likely
to reduce condom inaccessibility as a barrier to condom use.
Despite the strengths of the study sample
and results, several aspects of the methodology
limit the conclusions that can be made. We surveyed a convenience sample of IDUs from SEPs in
California, and we did not systematically obtain refusal rates. Therefore, our results may not generalize
to other IDU populations or SEP users, and individuals who refused may have differed in meaningful
ways from those who were surveyed. Further, the
condom attitudes, preferences, and barriers observed
in the present study may be unique to this sample
and should not be generalized to other members
of populations who engage in risky behaviors (e.g.,
men who have sex with men). In addition, because
a cross-sectional design was used, we were unable to
examine the direction of causality between condom
attitudes and condom behaviors. Because condom
use behavior was measured retrospectively, and attitudes were measured at the time of the survey, we
do not know whether attitudes preceded behavior,
or attitudes were formed on the basis of the reported
behaviors. Thus, in-depth longitudinal studies that
measure condom use attitudes and behaviors at
multiple time-points are needed to understand the
nature of the relations between these constructs.
Nevertheless, the data presented here were obtained from a large sample of IDUs and demonstrate
the utility of examining attitudes about condom use
when predicting sexual risk behavior. Unprotected
sexual contact with IDUs is a rapidly growing risk
factor for HIV (Kral et al., 2001; Strathdee et al.,
2001), and understanding condom use barriers,
attitudes, and preferences is a first step to changing
Condom Attitudes Among IDUs
sexual risk behaviors. Interventions that increase
awareness about positive aspects of condom use,
distribute condom types requested by its clients, and
work to eliminate misconceptions about partner risk,
HIV, and condoms, are likely to be successful in
decreasing sexual risk behavior among IDUs.
ACKNOWLEDGMENTS
The authors would like to thank the Centers for Disease Control and Prevention for funding the California Syringe Exchange Program Study
(Grant #RO6/CCR918667). The authors also thank
Christopher Buck and Kathryn Anderson in Santa
Monica and Lynell Clancy in Sacramento. The
project is indebted to the syringe exchange programs
in California that agreed to participate and refer their
clients to this study.
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